1. Hess, Cathy Thomas BSN, RN, CWOCN

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In my recent Practice Points columns, we have discussed "Clinical Quality Measures and Meaningful Use" (May 2014) and "Quality Measures and Physician Quality Reporting System" (June 2014). Within each column, we discussed the importance of each program and how it truly benefits you. I have received a number of questions related to each program-specifically, the intentions and timelines. Although both programs provide incentives through their respective methods of quality reporting, I wanted to ensure a clear understanding of Meaningful Use and Physician Quality Reporting System (PQRS) opportunities and important timelines for each program.


Meaningful Use Attestation Through the Certified Electronic Health Record

The Centers for Medicare & Medicaid (CMS) Electronic Health Record (EHR) Incentive Program provides financial incentives for the "meaningful use" of certified EHR technology. Attestation is the part of the process to secure CMS EHR Incentive Program reimbursements that requires providers to prove (attest to) that they are meaningfully using a certified EHR.


To receive an EHR incentive payment, providers have to show that they are "meaningfully using" their certified EHR technology by meeting certain measurement thresholds that range from recording patient information as structured data to exchanging summary care records. The CMS has established these thresholds for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs).


The CMS EHR Incentive Programs include 3 stages with increasing requirements for participation. All providers begin participating by meeting the Stage 1 requirements for a 90-day period in their first year of meaningful use and a full year in their second year of meaningful use. After meeting the Stage 1 requirements, providers will then have to meet Stage 2 requirements for 2 full years. Eligible professionals participate in the program on the calendar years, whereas eligible hospitals and CAHs participate according to the federal fiscal year.


Meaningful Use Timeline in 2014: Timing Is Critical

If you choose to participate in the Medicare EHR Incentive Program for the first time in 2014, you should begin your 90-day reporting period no later than July 1, 2014, and submit attestation by October 1, 2014, to avoid the payment adjustment in 2015. Eligible professionals must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years.


Eligible professionals may be exempt from payment adjustments if they can show that demonstrating meaningful use would result in a significant hardship. To learn more about the Hardship Exemption for the EP, visit


PQRS Facts

The PQRS is a CMS program that uses a combination of incentive payments and adjustments to promote reporting of quality information by EPs. Specifically, the reported data focus on quality measures for covered Physician Fee Schedule services furnished to Medicare Part B Fee-for-Service beneficiaries. Eligible professionals may choose at least 9 individual measures across 3 National Quality Strategy Domains or 1 measures group as an option to report on measures to CMS.


PQRS Timeline in 2014: Timing Is Critical

Any EPs who do not participate in PQRS reporting in 2014 will face negative payment adjustments, beginning in 2015. Please refer to the June 2014 Practice Points column for more information. In addition, the CMS provides a PQRS Interactive Timeline to assist in identifying key program dates for PQRS between 2014 and 2016 and provides related resources. This information can be found at


If you are already participating in PQRS, you are not required to select new/different measures for the 2014 PQRS.


Note: All PQRS measure specifications are annually updated and posted prior to the beginning of each program year; therefore, EPs will need to review the measures for any revisions or measure retirement for the current program year.


Should you need assistance in understanding the step-by-step process to achieve Meaningful Use or PQRS, feel free to e-mail me at chess@nhsinc.comr. Good luck!